Doctor, What Is Sinusitis?
Acute Community-Acquired Sinusitis: A Review of Epidemiology and Management
Jeffrey Lauer, MD   Infect Med 20(1):44-48, 2003. © 2003

 NORMAL SINUS                    SINUSITIS

 Doctor, What Is Sinusitis?
Sinus Facts
Have you ever had a cold or allergy attack that wouldn't go away? If so, there's a good chance you actually had sinusitis. Experts estimate that 37 million people are afflicted with sinusitis each year, making it one of the most common health conditions in America. That number may be significantly higher, since the symptoms of bacterial sinusitis often mimic those of colds or allergies, and many sufferers never see a doctor for proper diagnosis and treatment with an antibiotic.

What is sinusitis?
Acute bacterial sinusitis is an infection of the sinus cavities caused by bacteria. It usually is preceded by a cold, allergy attack, or irritation by environmental pollutants. Unlike a cold, or allergy, bacterial sinusitis requires a physician's diagnosis and treatment with an antibiotic to cure the infection and prevent future complications.
Normally, mucus collecting in the sinuses drains into the nasal passages. When you have a cold or allergy attack, your sinuses become inflamed and are unable to drain. This can lead to congestion and infection. Diagnosis of acute sinusitis usually is based on a physical examination and a discussion of your symptoms. Your doctor also may use x-rays of your sinuses or obtain a sample of your nasal discharge to test for bacteria.
When Acute Becomes Chronic Sinusitis
When you have frequent sinusitis, or the infection lasts three months or more, it could be chronic sinusitis. Symptoms of chronic sinusitis may be less severe than those of acute; however, untreated chronic sinusitis can cause damage to the sinuses and cheekbones that sometimes requires surgery to repair.
Treating Sinusitis
Bacterial sinusitis: Therapy for bacterial sinusitis should include an appropriate antibiotic. If you have three or more symptoms of sinusitis (see chart), be sure to see your doctor for diagnosis. In addition to an antibiotic, an oral or nasal spray or drop decongestant may be recommended to relieve congestion, although you should avoid prolonged use of nonprescription nasal sprays or drops. Inhaling steam or using saline nasal sprays or drops can help relieve sinus discomfort.
Antibiotic Resistance
Antibiotic resistance means that some infection-causing bacteria are immune to the effects of certain antibiotics prescribed by your doctor. Antibiotic resistance is making even common infections, such as sinusitis, challenging to treat. You can help prevent antibiotic resistance. If the doctor prescribes an antibiotic, it is important that you take all of the medication just as your doctor instructs, even if your symptoms are gone before the medicine runs out.
Chronic Sinusitis
If your doctor thinks you have chronic sinusitis, intensive antibiotic therapy may be prescribed. Surgery is sometimes necessary to remove physical obstructions that may contribute to sinusitis.
Sinus Surgery
Surgery should be considered only if medical treatment fails or if there is a nasal obstruction that cannot be corrected with medications. The type of surgery is chosen to best suit the patient and the disease. Surgery can be performed under the upper lip, behind the eyebrow, next to the nose or scalp, or inside the nose itself.
Functional endoscopic sinus surgery (FESS) is recommended for certain types of sinus disease. With the endoscope, the surgeon can look directly into the nose, while at the same time, removing diseased tissue and polyps and clearing the narrow channels between the sinuses. The decision whether to use local or general anesthesia will be made between you and your doctor, depending on your individual circumstances.
Before surgery, be sure that you have realistic expectations for the results, recovery, and postoperative care. Good results require not only good surgical techniques, but a cooperative effort between the patient and physician throughout the healing process. It is equally important for patients to follow pre- and postoperative instructions.
Preventing Sinusitis
As always, an ounce of prevention is worth a pound of cure. To avoid developing sinusitis during a cold or allergy attack, keep your sinuses clear by:
using an oral decongestant or a short course of nasal spray decongestant
gently blowing your nose, blocking one nostril while blowing through the other
drinking plenty of fluids to keep nasal discharge thin
avoiding air travel. If you must fly, use a nasal spray decongestant before take-off to prevent blockage of the sinuses allowing mucus to drain
If you have allergies, try to avoid contact with things that trigger attacks. If you cannot, use over-the-counter or prescription antihistamines and/or a prescription nasal spray to control allergy attacks
Allergy testing, followed by appropriate allergy treatments, may increase your tolerance of allergy-causing substances. If you believe you may have sinusitis, see our tips for sinusitis sufferers.
When to See a Doctor
Because the symptoms of sinusitis sometimes mimic those of colds and allergies, you may not realize you need to see a doctor. If you suspect you have sinusitis, review these signs and symptoms. If you suffer from three or more, you should see your doctor.
Facial Pressure/
Duration of Illness
Over 10-14 days
Under 10 days
Nasal Discharge
Thick, yellow-green
Clear, thin, watery
Thick, whitish or thin
Pain in Upper Teeth
Bad Breath
Nasal Congestion
A Word about Children
Your child's sinuses are not fully developed until age 20. However, children can still suffer from sinus infection. Although small, the maxillary (behind the cheek) and ethmoid (between the eyes) sinuses are present at birth. Sinusitis is difficult to diagnose in children because respiratory infections are more frequent, and symptoms can be subtle. Unlike a cold or allergy, bacterial sinusitis requires a physician's diagnosis and treatment with an antibiotic to prevent future complications.
The following symptoms may indicate a sinus infection in your child:
a "cold" lasting more than 10 to 14 days, sometimes with low-grade fever
thick yellow-green nasal drainage
post-nasal drip, sometimes leading to or exhibited as sore throat, cough, bad breath, nausea and/or vomiting
headache, usually not before age 6
irritability or fatigue
swelling around the eyes
If despite appropriate medical therapy these symptoms persist, care should be taken to seek an underlying cause. The role of allergy and frequent upper respiratory infections should be considered.

 Fact Sheet: 20 Questions about Your Sinuses
Q. How common is sinusitis?

A. More than 37 million Americans suffer from at least one episode of acute sinusitis each year. The prevalence of sinusitis has soared in the last decade possibly due to increased pollution, urban sprawl, and increased resistance to antibiotics.

Q. What is sinusitis?

A. Sinusitis is an inflammation of the membrane lining of any sinus, especially one of the paranasal sinuses. Acute sinusitis is a short-term condition that responds well to antibiotics and decongestants; chronic sinusitis is characterized by at least four recurrences of acute sinusitis. Either medication or surgery is a possible treatment.

Q. What are the signs and symptoms of acute sinusitis?

A. For acute sinusitis, symptoms include facial pain/pressure, nasal obstruction, nasal discharge, diminished sense of smell, and cough not due to asthma (in children). Additionally, sufferers of this disorder could incur fever, bad breath, fatigue, dental pain, and cough.

Acute sinusitis can last four weeks or more. This condition may be present when the patient has two or more symptoms and/or the presence of thick, green or yellow nasal discharge. Acute bacterial infection might be present when symptoms worsen after five days, persist after ten days, or the severity of symptoms is out of proportion to those normally associated with a viral infection.

Q. How is acute sinusitis treated?

A. Acute sinusitis is generally treated with ten to 14 days of antibiotic care. With treatment, the symptoms disappear, and antibiotics are no longer required for that episode. Oral and topical decongestants also may be prescribed to alleviate the symptoms.

Q. What are the signs and symptoms of chronic sinusitis?

A. Victims of chronic sinusitis may have the following symptoms for 12 weeks or more: facial pain/pressure, facial congestion/fullness, nasal obstruction/blockage, thick nasal discharge/discolored post-nasal drainage, pus in the nasal cavity, and at times, fever. They may also have headache, bad breath, and fatigue.

Q. What measures can be taken at home to relieve sinus pain?

A. Warm moist air may alleviate sinus congestion. Experts recommend a vaporizer or steam from a pan of boiled water (removed from the heat). Humidifiers should be used only when a clean filter is in place to preclude spraying bacteria or fungal spores into the air. Warm compresses are useful in relieving pain in the nose and sinuses. Saline nose drops are also helpful in moisturizing nasal passages.

Q. How effective are non-prescription nose drops or sprays?

A. Use of nonprescription drops or sprays might help control symptoms. However, extended use of non-prescription decongestant nasal sprays could aggravate symptoms and should not be used beyond their label recommendation. Saline nasal sprays or drops are safe for continuous use.

Q. How does a physician determine the best treatment for acute or chronic sinusitis?

A. To obtain the best treatment option, the physician needs to properly assess the patient' s history and symptoms and then progress through a structured physical examination.

Q. What should one expect during the physical examination for sinusitis?

A. At a specialist' s office, the patient will receive a thorough ear, nose, and throat examination. During that physical examination, the physician will explore the facial features where swelling and erythema (redness of the skin) over the cheekbone exist. Facial swelling and redness are generally worse in the morning; as the patient remains upright, the symptoms gradually improve. The physician may feel and press the sinuses for tenderness. Additionally, the physician may tap the teeth to help identify an inflamed paranasal sinus.

Q. What other diagnostic procedures might be taken?

A. Other diagnostic tests may include a study of a mucous culture, endoscopy, x-rays, allergy testing, or CT scan of the sinuses.

Q. What is nasal endoscopy?

A. An endoscope is a special fiber optic instrument for the examination of the interior of a canal or hollow viscus. It allows a visual examination of the nose and sinus drainage areas.

Q. Why does an ear, nose, and throat specialist perform nasal endoscopy?

A. Nasal endoscopy offers the physician specialist a reliable, visual view of all the accessible areas of the sinus drainage pathways. First, the patient' s nasal cavity is anesthetized; a rigid or flexible endoscope is then placed in a position to view the nasal cavity. The procedure is utilized to observe signs of obstruction as well as detect nasal polyps hidden from routine nasal examination. During the endoscopic examination, the physician specialist also looks for pus as well as polyp formation and structural abnormalities that may cause recurrent sinusitis.

Q. What course of treatment will the physician recommend?

A. To reduce congestion, the physician may prescribe nasal sprays, nose drops, or oral decongestants. Antibiotics will be prescribed for any bacterial infection found in the sinuses (antibiotics are not effective against a viral infection). Antihistamines may be recommended for the treatment of allergies.

Q. Will any changes in lifestyle be suggested during treatment?

A. Smoking is never condoned, but if one has the habit, it is important to refrain during treatment for sinus problems. A special diet is not required, but drinking extra fluids helps to thin mucus.

Q. When is sinus surgery necessary?

A. Mucus is developed by the body to act as a lubricant. In the sinus cavities, the lubricant is moved across mucous membrane linings toward the opening of each sinus by millions of cilia (a mobile extension of a cell). Inflammation from allergy causes membrane swelling and the sinus opening to narrow, thereby blocking mucus movement. If antibiotics are not effective, sinus surgery can correct the problem.

Q. What does the surgical procedure entail?
A. The basic endoscopic surgical procedure is performed under local or general anesthesia. The patient returns to normal activities within four days; full recovery takes about four weeks.

Q. What does sinus surgery accomplish?

A. The surgery should enlarge the natural opening to the sinuses, leaving as many cilia in place as possible. Otolaryngologist--head and neck surgeons have found endoscopic surgery to be highly effective in restoring normal function to the sinuses. The procedure removes areas of obstruction, resulting in the normal flow of mucus.

Q. What are the consequences of not treating infected sinuses?

A. Not seeking treatment for sinusitis will result in unnecessary pain and discomfort. In rare circumstances, meningitis or brain abscess and infection of the bone or bone marrow can occur.

Q. Where should sinus pain sufferers seek treatment?

A. If you suffer from severe sinus pain, you should seek treatment from an otolaryngologist--head and neck surgeon, a specialist who can treat your condition with medical and/or surgical remedies.

The sinuses are cavities within the skull. They drain into the nose through small holes. Sinusitis means inflammation of the nasal sinuses. Sinusitis is most commonly short-lived, such as after a viral "cold". Blockage of the drainage pathways, however, creates an environment that favours the overgrowth of bacteria resulting in long-term (chronic) sinusitis. Hayfever and polyps are the most common reasons for having recurrent or chronic sinus infection.

What are sinuses?
The sinuses are cavities within the skull. They are present in the forehead cheeks and between and behind the eyes. They are connected to the nose through small tunnels that are little wider than a pinhead. Blockage of these tunnels (due to allergy, colds or polyps) often causes pain in the face. A blocked sinus cavity creates an environment that favors the overgrowth of bacteria, a little how slime grows in stagnant water. It is believed that the main function of nasal sinuses is to warm, moisten and filter the air in the nasal cavity. They also play a role in our ability to make certain sounds when we speak or sing.
Viral "colds" and allergies are the main risk factors for developing sinusitis
Sinusitis means inflammation of the lining of the nasal sinuses. Inflammation may be due to infection, or may have other causes. When infection is the cause, symptoms often follow simple viral colds. These generally last less than 3 weeks (acute sinusitis). Longer-lasting symptoms may indicate nasal allergy or the development of a bacterial sinus infection, complicating the common cold. Other risk factors for developing recurrent or chronic sinusitis include untreated allergies, twisted nasal anatomy, smoking, nasal polyps and overuse of over-the-counter decongestant nasal sprays.
 There are many symptoms and signs of sinusitis
Symptoms of sinusitis will vary according to the duration and severity of symptoms and which sinuses are involved. Some or all of the following symptoms may be present. You should see your doctor promptly if these symptoms develop.
- green / yellow mucus coming from the nose or down the back of the throat
- bad breath
- bad taste in the mouth
- sore throat
- losing the sense of smell or taste
- cough
- tiredness
- temperature or shivers
- sore upper teeth
- facial pain (but not always)
- sensation of pressure that is worse with leaning forward.
Untreated allergies are the most common risk factor for developing sinusitis
Allergy causes chronic inflammation and swelling of the lining of the nose, sinuses and the drainage holes that link them. This swelling interferes with the usual efficient clearance of bacteria from the sinus cavity. If one develops a viral "cold" as well, secretions and bacteria are trapped, creating an environment where bacteria grow very well. Allergy treatment will reduce the risk of developing sinusitis.
Environmental irritants also increase the symptoms of sinusitis
People with sinus problems and allergies should avoid environmental irritants such as tobacco, smoke and odours, which may increase symptoms. Twisted nasal anatomy, the presence of nasal polyps, overuse of decongestant nose sprays over the counter from the pharmacy can predispose to infection. Those involved with young children (such as young mums, child care workers and primary school teachers) always seem to have a cold! Diet plays no role in causing or preventing infection. A weak immune system is a very rare cause.

Effective treatment depends on correct diagnosis
Many people wrongly label their allergies as "sinus trouble", but not all of them are troubled by infection. Your doctor will normally ask questions to identify the cause of your problem. This may be followed by physical examination of nasal anatomy and allergy testing (using skin tests or RAST) to help confirm or exclude the presence of allergy as a cause or risk factor for your symptoms. Sometimes other tests such as x-rays of the sinuses or tests of immune function may be needed.
Sinusitis versus Rhinitis
Although many symptoms are similar, it is important that sinusitis is not mistaken for rhinitis. The term rhinitis means inflammation of the lining of the nose. It is often caused by allergies, irritants such as smoke, temperature changes or the overuse of decongestant nasal sprays. Poorly controlled rhinitis can, however, lead to sinusitis.
Early treatment of sinusitis reduces the need for medication
Around half of all sinusitis resolve without antibiotics. Treat symptoms promptly when first noticed often reduces the need for antibiotics. There are three principles of treatment:
Help the sinuses to drain. Salt water irrigation of the nose and sinuses thin mucus and aid sinus drainage. Commercial sprays such as Narium or FESS can be purchased from your pharmacist and used 2 or 3 times per days. Steam inhalations can also help but should be avoided in children as they may suffer from accidental burns. Surgery is sometimes needed when maximal medical therapy fails to help.
Kill the germs. If symptoms persist, appropriate antibiotics should be prescribed for an adequate duration (generally 10 - 14 days for acute sinusitis and 3-4 weeks for chronic sinusitis)
Treat underlying disease. This may involved treating your allergies, stopping smoking or removing nasal polyps.
It is important to note that information contained in this bulletin is not intended to
replace professional medical advice. Any questions regarding a medical
diagnosis or treatment should be directed to a medical practitioner.
Joint Task Force on Practice Parameters, Joint Council of Allergy, Asthma and Immunology. Parameters for the diagnosis and management of sinusitis. J Allergy Clin Immunology 1998; 102 (6, part 2): s107-144.
Slavin RG. Chronic sinusitis. Immun Allergy Clin N America 1996; 16: 35-47.
Kaliner MA et al. Sinusitis: bench to bedside. J Allergy Clin Immunol 1997; 99: S829-48.


Acute Community-Acquired Sinusitis: A Review of Epidemiology and Management
Jeffrey Lauer, MD
Infect Med 20(1):44-48, 2003. © 2003 Cliggott Publishing, Division of SCP Communications
Posted 02/28/2003
Abstract and Introduction
Acute sinusitis has multiple viral and bacterial causes and may affect any of the paranasal sinuses. Viral rhinosinusitis is extremely common, and as many as 2% of cases are complicated by acute bacterial sinusitis. Clinical findings have limited sensitivity and specificity, and initial treatment is usually empiric. When complications such as orbital cellulitis occur, sinus CT scans and cultures may be required to guide therapy.
The paranasal sinuses are aerated cavities in the bones of the face that develop as outpouches of the nasal cavity and communicate with this cavity throughout life. The maxillary and ethmoidal sinuses are present at birth; the frontal and sphenoidal sinuses develop after ages 2 and 7 years, respectively.[1] The sinuses reduce overall skull weight, participate in warming and humidification of inspired air, and add resonance to the voice. The sinuses are lined with ciliated pseudostratified epithelium containing mucus-producing goblet cells, similar to the lining of the nasal cavity but with less density.[2] The beating cilia carry mucus and contaminants out of the sinuses toward the sinus openings (ostia) at a speed of up to 1 cm/min.[3] The mucous blanket changes 2 to 3 times each hour.
Obstruction of the ostia and/or delay in mucociliary transport leads to accumulation of secretions and subsequently to the development of sinusitis. Unlike the nasal passages, the paranasal sinuses are normally sterile. The mechanisms maintaining this sterility include the mucociliary clearance system, the immune system, and possible nitric oxide production within the sinus cavity.[4,5]
The classification of sinusitis can be based on a number of factors, including the patient's immune status, the causative pathogen (viral, bacterial, fungal), and the duration of the sinusitis (acute, subacute, chronic, recurrent). Acute sinusitis is defined as sinusitis lasting 4 weeks or less, while sinusitis is considered subacute when symptoms persist for 4 to 12 weeks and chronic when symptoms last longer than 12 weeks. During the first 7 to 10 days of illness, it may be difficult to determine whether the symptoms are caused by a viral or bacterial pathogen and to decide whether antimicrobials are indicated. Appropriate classification of the cause is important so that the correct treatment can be defined and instituted and treatment outcomes can be evaluated. This article will focus on acute community-acquired bacterial sinusitis, highlighting various aspects of the other types of sinusitis only to demonstrate relationships, similarities, and differences.
Viral Rhinosinusitis
The maxillary sinus is the one most commonly involved with any type of sinusitis, followed in frequency by the ethmoidal, frontal, and sphenoidal sinuses. The most common precursor to bacterial sinusitis is a viral infection of the upper respiratory tract, referred to as viral rhinosinusitis (VRS). VRS is defined as an initial viral syndrome resulting in thickening of sinus mucosa, possible obstruction of the ostia, and the signs and symptoms of classic sinusitis with or without rhinitis. It is unclear whether the presence of the virus in the sinus is needed for the sinus symptoms or whether symptoms result solely from the associated inflammatory response. VRS usually resolves within 7 to 10 days without specific therapy. Two new antiviral agents, pleconaril and AG7088, are currently being evaluated as therapies for VRS caused by rhinoviruses or enteroviruses. It is hoped that these will be effective in shortening the clinical course of VRS.
Epidemiology and Causes of Acute Bacterial Sinusitis
It is estimated that 0.5% to 2% of cases of VRS are complicated by clinically evident acute bacterial sinusitis. In the United States, the incidence of VRS is estimated to be 2 or 3 episodes per year in adults and twice that number in children. Using the US population and an average 4 VRS episodes per year, an estimated 1 billion cases of VRS occur annually, with an expected progression to acute bacterial sinusitis in up to 20 million patients.[2] The 1997 data from the National Ambulatory Medical Care Survey indicated 959.2 million ambulatory care visits, of which 2.8 million were for presumed acute bacterial sinusitis.[6] Thus, it would appear that 1 in 100 patients with VRS and 1 in 10 patients with acute sinusitis seek physician care for their illness.
VRS and its complication of acute bacterial sinusitis have seasonal patterns of occurrence based on the virus involved. In early fall and late spring, rhinovirus is the most common cause, while in winter and early spring, the likely agents are coronavirus, respiratory syncytial virus, and influenza virus. Acute community-acquired sinusitis can result from other causes that demonstrate no particular seasonal pattern, such as swimming (with microaspiration of water into the upper airway); allergies; and nasal obstruction secondary to polyps, tumor, or foreign bodies. Also, those persons with defects in immunity (eg, those with HIV infection or agammaglobulinemia), delayed or absent mucociliary activity (eg, those with Kartagener syndrome or cystic fibrosis), structural defects (eg, those with cleft palate), or functional abnormalities of white blood cells (eg, those with chronic granulomatous disease or Wegener granulomatosis) are at risk for acute sinusitis that may occur regularly or progress to chronic sinus disease.
Dental infections may cause 5% to 10% of all cases of maxillary sinusitis; the roots of the upper back teeth (second bicuspid, first and second molars) abut the floor of the maxillary sinus. Also, smoking may be implicated as a causative factor by means of smoking-induced nasopharyngeal lymphoid hyperplasia[7] and reduced ciliary clearance.[8,9]
The pathogenesis of VRS and acute community-acquired bacterial sinusitis is still debated. The most widely investigated viral pathogen is the rhinovirus. It has a unique ability to evade the host defenses in the upper respiratory tract, and in nonimmune volunteers, it has a greater than 90% infection rate after intranasal inoculation.[10] After deposition in the nose, there is presumed transport to the posterior pharynx and attachment to rhinovirus receptor intercellular adhesion molecule 1.[11] It is the resultant inflammatory and parasympathetic responses, rather than any direct cytotoxic effect of the virus, that cause the classic symptoms of the cold and the physical changes noted in the sinuses. Sinus cavity abnormalities were seen on CT scans from 87% of patients with colds; these abnormalities may involve any of the paranasal sinuses (Table 1).
The inflammatory process results in increased mucosal edema, increased mucus production, and delayed or absent mucociliary clearance with eventual ostial obstruction. Without adequate physiologic sinus drainage, bacteria that normally colonize the nasal passages or the pharynx can be deposited into the sinuses when a person sneezes, coughs, or blows his or her nose. This process is believed to account for the development of acute community-acquired bacterial sinusitis following an upper respiratory tract viral illness.
Manifestations of Sinusitis
Symptoms of VRS and acute bacterial sinusitis can include purulent nasal or postnasal drainage, nasal congestion, and sinus pain or pressure. The location of the sinus pain or pressure depends on the sinus involved. Maxillary sinus pain is often perceived as being located in the cheek or upper teeth; ethmoidal si-nus pain, between the eyes or retro-orbital; frontal sinus pain, above the eyebrow; and sphenoidal sinus pain, in the upper half of the face or retro-orbital with radiation to the occiput. Sinus pain is frequently worse when the patient bends forward or is supine. These symptoms, although suggestive of sinus involvement, obviously do not identify the cause. If they occur early in the course of an illness, they may represent a viral or bacterial origin.
The persistence of cold symptoms for more than 7 to 10 days (or longer than usual for a particular patient) is the most consistent clinical feature of acute bacterial sinusitis.[12] Complete opacification of the maxillary or frontal sinus, shown by transillumination with a strong flashlight, constitutes good evidence of sinusitis. However, the differentiation of viral from bacterial sinusitis or a combination of viral-bacterial sinusitis can be difficult.
Many of the clinical findings routinely used to evaluate for sinusitis have limited sensitivity and specificity. The Task Force on Rhinosinusitis of the American Academy of Otolaryngology-Head and Neck Surgery proposed major and minor factors that could be used to tentatively diagnose sinusitis.[13-15] The diagnosis requires the presence of at least 2 major factors or 1 major and 2 minor factors. The major factors include facial pain or pressure, facial congestion or fullness, nasal obstruction, nasal purulence or discolored postnasal drainage, and fever (in acute sinusitis only). The minor factors are headache; fever (in nonacute sinusitis); halitosis; fatigue; dental pain; cough; and ear pain, pressure, or fullness.
Besides the clinical evaluation for sinusitis, radiologic imaging has been used routinely. Four-view sinus x-ray films are helpful when looking for opacity, an air-fluid level, or 4 mm or more of sinus mucosal thickening. CT is more sensitive than routine radiography. In many institutions, the cost of CT limited to the sinuses is comparable to the cost of sinus radiography. Because of their lack of specificity, however, imaging studies are not recommended for the routine diagnosis of community-acquired sinusitis. Patients with VRS have sinus CT scan abnormalities that usually cannot be distinguished from those associated with acute community-acquired bacterial sinusitis,[10] especially early in the disease process.
The viral and bacterial organisms that usually cause acute community-acquired sinusitis have been well identified, especially for the maxillary sinuses (Table 2).[16] The causes have changed little over the years, with maxillary sinus puncture microbiology in 1948 demonstrating Haemophilus influenzae, Diplococcus (Streptococcus) pneumoniae, or Streptococcus hemolyticus (Streptococcus pyogenes).[17] The 3 major bacterial pathogens in acute community-acquired sinus-itis in adults are S pneumoniae, H influenzae (not type b), and Moraxella catarrhalis. In adults, gram-negative bacilli play a role (9% of cases), and anaerobes (6%) are especially important in cases associated with dental infections.
Although clinical symptoms compatible with sinusitis frequently occur in patients with Chlamydia pneumoniae respiratory infections, no studies have demonstrated a causal relationship. In patients with deficits involving humoral and cell-mediated immunity, such as in HIV infection, the involved agents are similar but with an increased incidence of Pseudomonas aeruginosa and Staphylococcus species, as determined from surgical cultures.[18,19]
Empiric therapy for acute bacterial sinusitis should be directed against the bacterial pathogens most commonly associated with this infection. Sinus puncture is not indicated in routine cases, and cultures of nasal drainage material are not very reliable.
A number of antimicrobials have broad activity against the usual pathogens associated with acute bacterial sinusitis. The b-lactam antimicrobials that continue to show the best activity against penicillin-sensitive and intermediately resistant strains of pneumococci, b-lactamase- producing H influenzae, and M catarrhalis are amoxicillin/clavulanate, cefpodoxime, and cefuroxime. In communities where there is a high prevalence of penicillin-resistant S pneumoniae (in some areas in the United States, 30% of strains or more are resistant), there is also an associated resistance to many of the other commonly used antibiotics, such as erythromycin, clarithromycin, and trimethoprim-sulfamethoxazole. In this situation, the oral second-generation cephalosporins cefadroxil and cefu-roxime axetil may be effective.
The newer quinolones levofloxacin, gatifloxacin, and lomefloxacin provide excellent activity against both penicillin-sensitive and -resistant S pneumoniae and other sinusitis pathogens.[10] Table 3 lists some drugs used to treat acute community-acquired bacterial sinusitis. A 10-day course of antibiotic therapy for acute bacterial sinusitis is usually effective, but some recommend 14 days. With the initiation of antibiotics for bacterial sinusitis, most symptoms begin to resolve within the first 48 to 72 hours. Failure to improve on completion of appropriate antibiotic therapy should prompt consideration of bacterial resistance, noncompliance, or complicated sinusitis.[12]
Proven ancillary therapy for acute community-acquired sinusitis includes oral decongestants, cough suppressants, NSAIDs, and antihistamines. Expectorants, such as guaifenesin, have theoretical value and are often used but are of unproven value in the treatment of sinusitis.[20 It is best to avoid topical cortico-steroids and decongestants, which, although initially effective, can cause rebound vasodilatation, nasal obstruction, and pharyngeal irritation.
The most common complication of sinusitis is orbital cellulitis. This condition usually arises from the ethmoidal sinuses but may also result from maxillary sinus involvement. Other possible complications include Pott puffy tumor; epidural, subdural, or cerebral abscess; meningitis; and cavernous sinus thrombophlebitis.[1] Patients with complicated sinusitis need CT evaluation to rule out a drainable focus and culture of the sinus to guide intravenous antibiotic therapy. While culture results are pending, treatment with a broad-spectrum parenteral antibiotic, such as nafcillin or ceftriaxone, with or without an aminoglycoside, should be started.
Table 1. Frequency of sinus abnormalities on CT scan in adults with early common colds

Occlusion of Infundibulum
Abnormality of sinus cavity
Adapted from Gwaltney JM Jr. In: Mandell GL et al, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 2000.[16]

Table 2. Viral and bacterial causes of acute community-acquired maxillary sinusitis

Mean percentage of cases (range)
Influenza virus
Parainfluenza virus
Streptococcus pneumoniae
31 (20-35)
Haemophilus influenzae (unencapsulated)
21 (6-26)
S pneumoniae + H influenzae
5 (1-9)
9 (3-19)
Moraxella catarrhalis
8 (2-10)
Anaerobic bacteria
6 (0-10)
Staphylococcus aureus
4 (0-8)
Streptococcus pyogenes
2 (1-3)
Gram-negative bacteria
9 (0-24)
Adapted from Gwaltney JM Jr. In: Mandell GL et al, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 2000.[16]

Table 3. Antimicrobials used to treat acute community- acquired bacterial sinusitis in adults

875 mg/125 mg q12h
200 mg q12h
Cefuroxime axetil*
250 mg q12h
500 mg q12h
500 mg q12h
500 mg qd
500 mg on day 1, then 250 mg qd on days 2-5; can repeat at 2 weeks if no improvement
500 mg tid
Proved effective by pretreatment and post-treatment sinus aspirate culture.
Adapted from Gwaltney JM Jr. In: Mandell GL et al, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 2000.[16]
Durand M, Joseph M, Baker AN. Infections of the upper respiratory tract. In: Fauci AS, Braunwald E, Isselbacher KJ, eds. Harrison's Principles of Internal Medicine. 14th ed. New York: McGraw Hill; 1998:179-180.
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Ahuja GS, Thompson J. What role for antibiotics in otitis media and sinusitis? Postgrad Med. 1998;104:93-104.
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Finkelstein Y, Malik Z, Kopolovic J, et al. Characterization of smoking-induced nasopharyngeal lymphoid hyperplasia. Laryngoscope. 1997; 107:1635-1642.
Mahakit P, Pumhirun P. A preliminary study of nasal mucociliary clearance in smokers, sinusitis and allergic rhinitis patients. Asian Pac J Allergy Immunol. 1995;13:119-121.
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Sidebar: Drugs Mentioned in This Article
Duricef, generic
Kefurox, Zinacef
Cefuroxime axetil
Ery-Tab, generic
Multiple products
Unipen, Nallpen
Bactrim, Septra, generic
The author thanks Dr Michael Sands for his manuscript review and editorial comments.

Jeffrey Lauer, MD, University of Florida and Duval County Health Department, Jacksonville